New York State Medicaid FeeforService FFS Pharmacy Prior

New York State Medicaid Fee-for-Service (FFS) Pharmacy Prior Authorization Programs Presented by: Magellan Medicaid Administration, Inc. & New York State Department of Health (DOH) Revised March 2014

Overview § What are the Medicaid FFS Pharmacy Prior Authorization (PA) Programs? § How do I obtain Prior Authorization? § Where can I go for more information? 2

Who is Subject to the FFS Pharmacy PA Programs? § Enrollees of the following program receive pharmacy services through NYS Medicaid Pharmacy Benefit Programs § Medicaid Fee-For-Service § Approximately 1. 5 million people § Will continue to present their Medicaid card at the pharmacy § Will continue to receive their pharmacy benefits from Medicaid until such time that they are moved into managed or care management 3

Preferred Drug Program (PDP) Implemented June 28, 2006 4

Preferred Drug Program (PDP) § Clinically driven & evidence-based § Maintains access to all drugs § Competitive pricing through supplemental rebates § Savings offset high drug costs 5

Preferred Drug List (PDL) § Categorized by therapeutic drug class § Preferred and non-preferred drugs § Footnotes provide useful information § Developed by the Drug Utilization Review (DUR) Board 6

DUR Board Meetings § Committee Members § Practicing physicians, nurse practitioners, pharmacists and patient advocates § Make recommendations on preferred status within PDP drugs classes § Review of existing therapeutic classes § Newly FDA-approved drugs § Addition of new therapeutic classes § Review and develop clinical criteria for PDP and the Clinical Drug Review Program (CDRP) 7

DUR Board Meetings § Public session announced on DOH website § Clinical Evidence & Discussion § § § Healthcare professionals Drug Effectiveness Review Project (Oregon Health & Sciences University) Pharmaceutical manufacturers and other interested parties § Executive Session § Financial information is considered only after the clinical discussion is completed § Committee formulates recommendations § Commissioner of Health makes the final determination 8

DUR Programs § Programs to help ensure that prescriptions for outpatient drugs are appropriate, medically necessary, and not likely to result in adverse medical consequences: § Step Therapy Program § Frequency/Quantity/Duration (F/Q/D) Program § Dose Optimization Program § DUR edits can be reviewed on the PDL: § https: //newyork. fhsc. com/downloads/providers/NYRx_PDP_PDL. pdf 9

DUR Programs § System editing will be performed at the point-of-sale to allow claims to pay without prior authorization when clinical criteria and F/Q/D limits are met § An automated approval will be issued if all rules associated with the requested product are satisfied; which will result in a paid claim § A failed clinical rule will result in a failed claim § A rejection message will be provided at the point-of-sale instructing pharmacy providers to notify the prescriber to change the prescription if appropriate or to obtain prior authorization § Prescribers must obtain prior authorization through the clinical call center for claims that do not meet clinical criteria 10

Brand When Less than Generic Program § Promotes the use of multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic § Do not require “DAW” or “Brand Medically Necessary” on the prescription § Please visit the following website for recent news and a listing of drugs subject to the program: § https: //newyork. fhsc. com/providers/bltgp_about. asp 11

Clinical Drug Review Program (CDRP) Implemented October 18, 2006 12

Intent of CDRP § To ensure that certain drugs are utilized in a medically appropriate manner § To protect the long-term efficacy of certain drugs and the public’s health § To prevent overuse, abuse and illegal utilization of certain drugs 13

Drugs/Classes Subject to CDRP An authorized agent* of the prescriber may initiate PA for the following: § Anabolic Steroids § Central Nervous System (CNS) Stimulants for age 18 & older § Fentanyl Mucosal Agents § Lidoderm® § Regranex® § Topical Immunomodulators § Truvada ® *An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i. e. nurse, medical assistant ) 14

Drugs/Classes Subject to CDRP The prescriber must initiate PA for the following: § § § Growth Hormones for age 21 years & older Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH Serostim® Synagis® Xyrem® Zyvox® 15

Additional CDRP Information § Defined clinical criteria has been established § Fax requests are not permitted for some CDRP drugs § PA requests may need to be escalated to the provider for additional information § Supporting documentation may be required for certain PA requests 16

Mandatory Generic Drug Program (MGDP) Implemented November 17, 2002 17

Mandatory Generic Drug Program § Originates from State statute which excludes Medicaid coverage of brand name drugs when an A-rated generic is available unless PA is obtained § Drugs subject to the PDP, CDRP and/or the Brand when Less Than Generic Initiative are not subject to this program § The following brand name drugs are exempt and do NOT require PA: § § § Clozaril® Coumadin® Dilantin® Gengraf® Lanoxin® § § § Levothyroxine Sodium (Unithroid®, Synthroid®, Levoxyl®) Neoral® Sandimmune® Tegretol® Zarontin® 18

Preferred Diabetic Supply Program (PDSP) Implemented October 1, 2009 19

Preferred Diabetic Supply Program § Preferred blood glucose monitors and corresponding test strips are available without prior approval or dispensing validation system (DVS) authorization § “Talking” and disposable blood glucose monitors are NOT included in the PDSP and will continue to be covered by Medicaid through the existing prior approval process § Preferred Supply List (PSL) is available online 20

How Do I Obtain Prior Authorization? 21

PDP, MGDP & CDRP PA Process § Dial (877) 309 -9493 and select option #1, then option #1 § Use the telephone key pad to enter: § Prescriber NPI § Prescriber Phone Number § Certified Pharmacy Technician will assist in completing PA § Faxing of PA requests to (800) 268 -2990 is available for PDP and some CDRP drugs § PAs can be obtained 24 hours a day, 7 days a week 22

DUR Program & PDSP PA Process § Drug Utilization Review Program § Dial (877) 309 -9493 and follow appropriate prompts § Preferred Diabetic Supply Programs § Dial (800) 342 -3005 to reach NYS DOH 23

Where Can I Go for More Information? 24

Program Updates Will be Communicated Through: § Email Notifications § Program Updates § Medicaid Update Article § Mailings § May be sent to prescribers most affected by program updates to minimize practice impact § Website Updates 25

https: //newyork. fhsc. com § PDL § PSL § Prior authorization fax form and worksheets § Clinical criteria § Material for enrollees 26

www. nyhealth. gov § Medicaid Update monthly publication § NYS health insurance & pharmacy programs § DUR Board § http: //www. nyhealth. gov/health_care/medicaid/program/dur/ 27

www. emedny. org § Formulary finder file § Provider enrollment forms & manuals § Patient eligibility verification instructions § Billing information § Fraud alerts 28

Important Numbers § Clinical Call Center: (877) 309 -9493 § Clinical Call Center Fax: (800) 268 -2990 § Diabetic Supply Prior Approval line: (800) 342 -3005 § Pharmacy Policy: (518) 486 -3209 § Enteral formula PA line: (866) 211 -1736 § Billing: (800) 343 -9000 29

New York State Medicaid Prior Authorization Programs Questions and Discussion 30